Provider Demographics
NPI:1225877293
Name:FULL BLOOM SPEECH LANGUAGE PATHOLOGY
Entity type:Organization
Organization Name:FULL BLOOM SPEECH LANGUAGE PATHOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH LANGUAGE PATHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:ELDER
Authorized Official - Suffix:
Authorized Official - Credentials:MA, SLP
Authorized Official - Phone:937-369-6613
Mailing Address - Street 1:17031 HUGH TORANCE PKWY
Mailing Address - Street 2:
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078-1276
Mailing Address - Country:US
Mailing Address - Phone:937-369-6613
Mailing Address - Fax:
Practice Address - Street 1:17111 KENTON DR STE 206B
Practice Address - Street 2:
Practice Address - City:CORNELIUS
Practice Address - State:NC
Practice Address - Zip Code:28031-5650
Practice Address - Country:US
Practice Address - Phone:937-369-6613
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-21
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty